Health Needs of Transgender People Remain Unmet

Fran Lowry

June 17, 2016

Despite the recent flurry of media attention that has been directed toward transgender people, they and their health needs remain poorly understood, experts say.

In a series of articles published online June 17 in the Lancet, experts on the transgender community outline some of the social and legal conditions in which transgender people live, as well as some of the medical perspectives that frame the provision of healthcare for these individuals.

The series was published to coincide with the World Professional Association for Transgender Health 24th Biennial Scientific Symposium, in Amsterdam, the Netherlands.

"Many transgender people live on the margins of society, facing stigma, discrimination, exclusion, violence, and poor health," write Sam Winter, PhD, Curtin University, Perth, Australia, and colleagues in the first of three articles in the series.

"Many of the health challenges faced by transgender people are exacerbated by laws and policies that deny them gender recognition," Dr Winter said in a statement.

"In no other community is the link between rights and health so clearly visible as in the transgender community. Faced with stigma, discrimination and abuse, transgender people are pushed to the margins of society, excluded from the workplace, their families and health care. Many are drawn into risky situations or behaviors, such as unsafe sex or substance abuse, which leave them at risk of further ill health," he said.

In the second article in the series, Kevan Wylie, MD, Porterbrook Clinic, Sheffield, United Kingdom, and colleagues note that although some clinical services for transgender people, including gender-affirming surgery, are best delivered in the context of more specialized facilities, most healthcare needs can be delivered by a primary care physician.

They add that although there is a dearth of educational programming about transgender health for healthcare professionals in general, there is support for introducing the topic early during medical school training and in the education of allied health professionals.

The majority of countries worldwide do not offer legal or administrative measures enabling gender recognition for transgender people. In Europe, eight countries fail to offer legal recognition to transgender people, and 17 countries still impose sterilization on people who seek gender recognition.

As of June 2016, Argentina, Denmark, Malta, Ireland, and Norway had laws that allow transgender people to determine their gender through an administrative process. Furthermore, Argentina and Malta affirm the right of transgender people to appropriate healthcare.

Several countries, including New Zealand, Australia, Nepal, Pakistan, and India, are also starting to recognize gender diversity beyond male and female, Dr Winter and colleagues write.

The series authors call for the following courses of action:

  • Revisions should be made to the World Health Organization's (WHO's) diagnostic manual, due in 2018, that would remove the diagnoses for transgender people from the chapter relating to mental and behavioral disorders to a chapter concerning conditions related to sexual health. "A mental health diagnosis is widely regarded as inappropriate and potentially harmful by reinforcing stigma. Such a move would be truly historic," the series authors state.

  • The WHO should reconsider the highly controversial diagnosis of "gender incongruence in childhood" for children who have not yet reached puberty and should focus efforts on providing children with access to better support and information for understanding and expressing their gender identity.

  • Healthcare for transgender people, including feminizing and masculinizing hormonal treatment, should be funded on the same basis as healthcare for nontransgender persons.

  • Physicians should be trained to understand the health needs of transgender people.

  • Governments should be prevented from instituting gender-reparative therapies for children, adolescents, and adults. Such measure are widely condemned as unethical.

"A comprehensive public health approach to address the health of transgender people requires access to gender affirmation services, evidence-based health-care delivery systems, and effective partnerships with local transgender communities," write Sari L. Reisner, ScD, Boston Children's Hospital, Harvard Medical School, and colleagues in the third article in the series.

Although there are substantial gaps in empirical research on transgender issues, "there are sufficient actionable data highlighting unique biological, behavioural, social, and structural contextual factors surrounding health risks and resiliencies for transgender people that need interventions," Dr Reisner and colleagues write.

"There are huge gaps in our understanding of transgender health stemming from a fundamental challenge of defining this diverse group and a failure to recognize gender diversity," Dr Reisner said in a statement.

"Nevertheless, we know enough to act. High rates of depression and HIV are all linked to the context in which transgender people are forced to live. In the past 15 years, there has been a dramatic shift from viewing transgender people as having a disorder towards a better understanding of gender diversity, but much more needs to be done," she said.

Beyond Bathrooms

Dr Reisner also coauthored a commentary on the subject in the New England Journal of Medicine.

"Visibility of transgender people and support for transgender rights have increased dramatically in recent years," Dr Reisner, Mark A. Schuster, MD, PhD, and Sarah E. Onorato, from Boston Children's Hospital, write.

"In 2015, a total of 375 Fortune 500 companies prohibited discrimination on the basis of gender identity, up from 15 in 2002. Nineteen states and the District of Columbia include gender identity in employment nondiscrimination laws," they write.

Nevertheless, transgender people still face substantial discrimination, they note.

"Beyond bathroom accessibility, discrimination is associated with increased stress, anxiety, depressive symptoms, post-traumatic stress disorder, substance abuse, and suicide. It is also associated with increased risk of bullying, verbal harassment, sexual assault, and nonsexual violence, as well as decreased healthcare utilization," they write.

The authors suggest that the medical community can play a crucial role in advocacy for transgender people and can provide a key voice in legislative hearings and amicus briefs.

"Establishing legal protection for transgender people in the United States may take time. Eliminating the need for such protection will no doubt take much longer. But being transgender, like being left-handed, may someday be recognized as merely another inherent human quality, no longer conferring a need for protection," they write.

But until then, "the health care community can better address transgender health needs, help ensure that transgender people feel safe in seeking health care, promote resilience in the face of prejudice, and expand our knowledge of how best to promote transgender health and well-being."

The series of articles in the Lancet was funded by the United Nations Development Programme. The authors have disclosed no relevant financial relationships.

Lancet. Published online June 17, 2016. Abstracts

N Engl J Med. Published online June 15, 2016. Full text

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